Billing Information

{{ Form::label('billing_name', 'Name On Card') }} {{ Form::text('billing_name', Input::old('billing_name')) }} {{ $errors->first('billing_name', ':message') }}

{{ Form::label('billing_address_line_1', 'Billing Address') }} {{ Form::text('billing_address_line_1', Input::old('billing_address_line_1')) }} {{ $errors->first('billing_address_line_1', ':message') }} {{ Form::label('address_line_2', 'Line 2', array('class' => 'secondary')) }} {{ Form::text('billing_address_line_2', Input::old('billing_address_line_2')) }} {{ $errors->first('billing_address_line_2', ':message') }}

{{ Form::label('billing_city', 'City') }} {{ Form::text('billing_city', Input::old('billing_city')) }} {{ $errors->first('billing_city', ':message') }}

{{ Form::label('billing_state', 'State') }} {{ Form::text('billing_state', Input::old('billing_state')) }} {{ $errors->first('billing_state', ':message') }}

{{ Form::label('billing_zip', 'Zipcode') }} {{ Form::text('billing_zip', Input::old('billing_zip')) }} {{ $errors->first('billing_zip', ':message') }}

Card Information

{{ Form::label('card_number', 'Card Number') }} {{ Form::text('card_number', Input::old('card_number'), array('class' => 'card_number')) }} {{ $errors->first('card_number', ':message') }} {{-- Form::label('card_type', 'Card Type') --}} {{ Form::hidden('card_type', 'visa', array('class' => 'card_type')) }}

{{ Form::label('card_cvc', 'CVC Code') }} {{ Form::text('card_cvc', Input::old('card_cvc')) }} {{ $errors->first('card_cvc', ':message') }}

{{ Form::label('card_expiration', 'Expiration Date') }} {{ Form::selectMonth('card_exp_month') }} / {{ Form::selectYear('card_exp_year', date('Y'), date('Y', strtotime("+10 years"))) }} {{ $errors->first('card_exp_month', ':message') }} {{ $errors->first('card_exp_year', ':message') }}